Mental Health Intake Form

Transcription

1 Mental Health Intake Form Please complete the information on this form and bring it to the first visit. It may seem long, but most of the questions require only a check. This form will be reviewed at your Intake appointment. If it has not been completed, you will be asked to fill it out in the lobby before seeing your provider. Thank you! Name Date Date of Birth Primary Care Physician Do you give permission for ongoing regular updates to be provided to your primary care physician? Please provide a good working phone number: What are the problem(s) for which you are seeking help? Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms): ( ) Depressed mood ( ) Racing thoughts ( ) Excessive worry ( ) Unable to enjoy activities ( ) Impulsivity ( ) Anxiety attacks ( ) Sleep pattern disturbance ( ) Increased risky behavior ( ) Avoidance ( ) Loss of interest ( ) Increased libido ( ) Hallucinations ( ) Concentration/forgetfulness ( ) Decrease need for sleep ( ) Suspiciousness ( ) Change in appetite ( ) Excessive energy ( ) Excessive guilt ( ) Increased irritability ( ) Fatigue ( ) Crying spells ( ) Decreased libido Suicide Risk Assessment: Have you ever had feelings or thoughts that you didn't want to live? ( ) Yes ( ) No. If YES, please answer the following. If NO, please skip to the next section. Do you currently feel that you don't want to live? ( ) Yes ( ) No How often do you have these thoughts? When was the last time you had thoughts of dying? Has anything happened recently to make you feel this way? Have you had recent thoughts of suicide? If Yes, do you have plan? (please explain) Is there anything that would stop you from killing yourself? Do you feel hopeless and/or worthless? Have you ever tried to kill or harm yourself before? Page 1

2 List ALL current prescription medications and how often you take them: (if none, write NONE) Medication: Dose: When Started: Current over-the-counter medications/supplements/vitamins: Trauma History: Do you have a history of being abused emotionally, sexually, physically or by neglect? ( ) Yes ( ) No;. If YES, please describe when, where and by whom: Have you been exposed to Domestic Violence? Legal History: Have you ever been arrested? Do you have any pending legal problems? Past Psychiatric History: Outpatient treatment ( ) Yes ( ) No; If yes, Please describe below: Reason: Dates: Provider: Psychiatric Hospitalization ( ) Yes ( ) No; If yes, describe below: Reason: Date/length of stay: Hospital: Past Psychiatric Medications: If you have ever taken any of the following medications, please state if they were helpful, and ANY side effects you can remember: Page 2

3 WHEN: DOSE: RESPONSE/SIDE EFFECTS: Antidepressants: Prozac (fluoxetine) Zoloft (sertraline) Luvox (fluvoxamine) Paxil (paroxetine) Celexa (citalopram) Lexapro (escitalopram) Effexor (venlafaxine) Cymbalta (duloxetine) Wellbutrin (bupropion) Remeron (mirtazapine) other Mood Stabilizers: Tegretol (carbamazepine) Lithium Depakote (valproate) Lamictal (lamotrigine) Topamax (topiramate) other Antipsychotics/Mood Stabilizers: Abilify (aripiprazole) Risperdal (risperidone) Seroquel (quetiapine) Zyprexa (olanzepine) Geodon (ziprasidone) Clozaril (clozapine) Haldol (haloperidol) Prolixin (fluphenazine) Other Sleep Medications: Ambien (zolpidem) Sonata (zaleplon) Rozerem (ramelteon) Restoril (temazepam) Desyrel (trazodone) Other ADHD medications Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Other Page 3

4 WHEN: DOSE: RESPONSE/SIDE EFFECTS: Antianxiety medications: Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Tranxene (clorazepate) Buspar (buspirone) Other Family Psychiatric History: Has anyone in your family been diagnosed with, or treated for: Bipolar disorder ( ) Yes ( ) No Schizophrenia ( ) Yes ( ) No Depression ( ) Yes ( ) No Post-traumatic stress ( ) Yes ( ) No Anxiety ( ) Yes ( ) No Alcohol abuse ( ) Yes ( ) No Anger ( ) Yes ( ) No Violence ( ) Yes ( ) No Other substance abuse ( ) Yes ( ) No Suicidal gestures If yes, whom had each problem? Substance Use: Do you think you may have a problem with alcohol or drug use? ( ) Yes ( ) No Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No If yes, for which substances? If yes, where were you treated and when? Check if you have ever tried the following: Yes / No; If yes, how long and when did you last use? Alcohol ( ) ( ) Cocaine ( ) ( ) Stimulants (pills) ( ) ( ) Heroin ( ) ( ) Marijuana ( ) ( ) Pain killers (not as prescribed) ( ) ( ) Methadone ( ) ( ) Sleeping pills ( ) ( ) Ecstasy ( ) ( ) Other *How many caffeinated beverages do you drink a day? Coffee Sodas Tea Energy Drinks? Page 4

5 Have you ever smoked cigarettes? ( ) Yes ( ) No Do you smoke currently? ( ) Yes ( ) No How many cigarettes/cigars per day on average? How many years? In the past? ( ) Yes ( ) No How many years did you smoke? When did you quit? Pipe, cigars, or chewing tobacco: Currently? ( ) Yes ( ); No In the past? ( ) Yes ( ) No What kind? How often per day on average? How many years? Family Background and Childhood History: Where did you grow up? List your siblings and their ages: Has anyone close to you died recently? Past Medical History: Allergies Current Weight Height Current medical problems: Past medical problems, including surgeries and prolonged hospital stays: Your Exercise Level: Do you exercise regularly? ( ) Yes ( ) No For women only: Date of last menstrual period Are you currently pregnant or do you think you might be pregnant? ( ) Yes ( ) No. Are you planning to get pregnant in the near future? ( ) Yes ( ) No Birth control method? How many times have you been pregnant? How many live births? Personal and Family Medical History: Yourself: Family: Thyroid Disease ( ) ( ) Anemia ( ) ( ) Liver Disease ( ) ( ) Chronic Fatigue ( ) ( ) Kidney Disease ( ) ( ) Diabetes ( ) ( ) Yourself: Family: Asthma/respiratory problems ( ) ( ) Stomach or intestinal problems -- ( ) ( ) Cancer (type) ( ) ( ) Fibromyalgia ( ) ( ) Heart Disease ( ) ( ) Epilepsy or seizures ( ) ( ) Chronic Pain ( ) ( ) Page 5

6 High Cholesterol ( ) ( ) High blood pressure ( ) ( ) Head trauma ( ) ( ) Liver problems ( ) ( ) Other ( ) ( ) Educational History: Highest Grade Completed? Did you attend college? Where? Major? Occupational History: Are you currently: ( ) Working ( ) Student ( ) Unemployed ( ) Disabled ( ) Retired How long in present position? What is/was your occupation? Where do you work? Have you ever served in the military? Relationship History and Current Family: Are you currently: ( ) Married ( ) Partnered ( ) Divorced ( ) Single ( ) Widowed How long? If not married, are you currently in a relationship? ( ) Yes ( ) No; If yes, how long? Are you sexually active? ( ) Yes ( ) No How would you identify your sexual orientation? ( ) straight/heterosexual ( ) lesbian/gay/homosexual ( ) bisexual ( ) transsexual ( ) unsure/questioning ( ) other ( ) prefer not to answer What is your spouse or significant other's occupation? Describe your relationship with your spouse or significant other: Have you had any prior marriages? ( ) Yes ( ) No;. If so, how many? Do you have children? ( ) Yes ( ) No; If yes, list ages and gender: List everyone who currently lives with you: Spiritual Life: Do you belong to a particular religion or spiritual group? ( ) Yes ( ) No If yes, what is the level of your involvement? Do you find your involvement helpful when you are having difficult times? ( ) Yes ( ) No Other comments or concerns: Page 6

7 Signature Date Emergency Contact Telephone # Page 7